Every finding on record at Allied Home Health Services, Inc.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 10/30/23 to 10/31/23. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 10/30/23 to 10/31/23. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative issues and Staff B was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A, B and C. Standard level deficiencies were cited as a result of the survey. Glossary: HHA Home Health Agency OT Occupational therapy POC Plan of Care SN skilled nurse ST Speech therapy

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure: 1. The patient was educated on potential health outcomes related to refusal of SN visits and; 2. Notify the physician of the patient's imminent discharge from agency services for continued refusal of SN visits for one (Patient #15) of 20 patients. Findings: Patient #15 A review of a POC for 08/03/23 to 09/29/23 showed a SN visit frequency of one time a week for nine weeks. A review of visit notes showed missed SN visits on 09/15/23 and on 09/22/23. Documentation showed no communication or education attempts to the patient for potential health outcomes related to refusal of SN visits and showed no documentation to the physician of the patient's continued refusal of SN visits and imminent discharge from agency services. On 10/31/23 at 1:17 p.m., Staff B stated there was no documentation of: 1. Communication attempts to educate the patient of potential health outcomes related to continued refusal of SN visits prior to discharge from agency services and; 2. No physician notification of the patient's imminent discharge from agency services for continued refusal of SN visits.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a transfer/discharge summary contained necessary medical information at the time of patient transfer/discharge for four (Patients #14, 15, 18 and #19) of 20 patients. Findings: A policy titled, Discharge Summary stated the discharge (transfer) summary is a summary of care received by the client from start of care through discharge (transfer). [It] documents the client’s status at time of discharge (transfer), identified unmet needs and includes instructions given to the client/family regarding medications, treatments, referrals and necessary follow up needs. The summary includes admission and discharge dates, reason for admission to home health, types of services provided with frequency of services, laboratory data, medications, discharge (transfer) condition, outcomes in meeting goals in the plan of care, post discharge instructions, reason for discharge and transfer information as applicable. If treatment goals and client outcomes have not been met the RN/Therapist will assure referrals to the agencies/institutions to meet the continuing client needs and a summary form shall be completed and sent within 2 business days of transfer. Patient #14 A section of an OASIS E (discharge/transfer assessment) titled discharge summary dated 07/26/23 showed no documentation of medical information related to the current course of illness and treatment, including a medications list, post discharge goals and treatment preferences. Documentation showed the patient was discharged to hospice on 07/26/23 and showed no documentation a discharge summary was provided to the physician of record and the receiving hospice service provider. Patient #15 A section of an OASIS E (discharge/transfer assessment) titled discharge summary dated 09/29/23 showed no documentation of medical information related to the current course of illness and treatment, including a medications list, post discharge goals and treatment preferences. Documentation showed the patient was discharged on 09/29/23 and showed no documentation a discharge summary was provided to the physician of record. Patient #18 A section of an OASIS E (discharge/transfer assessment) titled discharge summary dated 09/06/23 showed no documentation of medical information related to the current course of illness and treatment, including a medications list, post discharge goals and treatment preferences. Documentation showed the patient was discharged on 09/06/23 and showed no documentation a discharge summary was provided to the physician of record. Patient #19 A section of an OASIS E (discharge/transfer assessment) titled discharge summary dated 08/28/23 showed no documentation of medical information related to the current course of illness and treatment, including a medications list, post discharge goals and treatment preferences. Documentation showed the patient was discharged on 08/28/23 and showed no documentation a discharge summary was provided to the physician of record. On 10/31/23 at 1:15 p.m. to 1:30 p.m., Staff B stated completed discharge/transfer summaries (a section of an OASIS E assessment) did not contain all required necessary medical information for patients #14, 15, 18 and #19.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure individualized patient POC included: 1. Weight reporting parameters for physician notification and weight related goals for one (Patient #6) of 20 and; 2. Pain reporting parameters for physician notification for two (Patients #9 and 15) of 20 patients. Findings: Patient #6 A review of the POC dated 08/28/23 to 10/26/23 showed orders for SN to assess, monitor and instruct patient’s weight every visit. POC documentation showed no weight reporting parameters for physician notification and no weight goals. SN visits conducted on 08/29/23 showed a weight of 82 pounds, 09/05/23 showed a weight of 80 pounds, 09/12/23 showed a weight of 82 pounds, 09/19/23 showed a weight of 97 pounds, 09/26/23 showed a weight of 98.6 pounds, 10/03/23 showed a weight of 98 pounds, 10/10/23 showed a weight of 100.4 pounds, 10/03/23 showed a weight of 98 pounds, 10/10/23 showed a weight of 100.4 pounds, 10/17/23 showed a weight of 101 pounds, and 10/23/23 showed a weight of 100 pounds. Documentation showed no physician notifications and no change in orders. Patient #9 A review of the POC dated 08/31/23 to 10/29/23 showed orders for SN to assess, monitor and instruct patient’s pain level every visit. POC documentation showed no pain reporting parameters for physician notification. SN visits conducted on 08/31/23 showed a pain level of 4/10 and on 10/05/23 showed a pain level of 2/10. Documentation showed no physician notifications and no change in orders. Patient #15 A review of the POC dated 08/03/23 to 09/29/23 showed orders for SN to assess, monitor and instruct patient’s pain level every visit. POC documentation showed no pain reporting parameters for physician notification. SN visits conducted on 09/15/23 showed a pain level of 10/10 and on 09/22/23 showed a pain level of 9/10. Documentation showed no physician notifications and no change in orders. On 10/31/23 at 12:57 p.m. to 1:17 p.m., Staff B stated POCs for patients #6, 9 and 15 showed no weight or pain level reporting parameters for physician notifications in the POCs.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. SN visits were conducted for three (Patients #1, 3 and 7) of 20 patients; 2. ST evaluation was conducted as ordered for one (Patient #3) of 20 patients; 3. SN conducted assessments of patients weight every visit for one (Patient #14) of 20 patients; 4. OT evaluation was conducted as ordered for two (Patient #3 and 8) of 20 patients and; 5. SN performed PICC line dressing change every week for one (Patient #12) of 20 patients. Findings: Patient #1 A review of a POC dated 09/13/23 to 11/11/23, showed orders for a SN visit frequency of one time a week for nine weeks. Documentation showed during the week 10/22/23 to 10/28/23 no SN visit was conducted (one visit ordered, one visit missed [electronic documentation system message showed not started]). Documentation showed no patient/caregiver refusal of the SN visits, no physician notifications and no change in orders. On 10/31/23 at 12:25 p.m., Staff B stated the SN should have conducted and documented the SN visits as ordered in the POC. Patient #3 A review of a POC dated 09/14/23 to 11/12/23, showed orders for a SN visit frequency of two times a week for two weeks, then once week for seven weeks. Documentation showed during the week 10/22/23 to 10/28/23 no SN visit was conducted (one visit ordered, one visit missed [electronic documentation system message showed not started]) and; OT evaluation and ST evaluation and treatment week of 09/14/23. Documentation showed no OT evaluation and an ST evaluation was conducted on 09/29/23. Documentation showed no attempts to complete the ST evaluation during the week it was ordered, no OT evaluation, no patient/caregiver refusal of the ST evaluation or SN visits, no physician notifications and no changes in orders. On 10/31/23 at 12:52 p.m., Staff B stated the SN should have conducted the SN visit, OT evaluation and the ST evaluation should have been conducted and documented as ordered in the POC. Patient #7 A review of a POC dated 09/09/23 to 11/07/23 showed orders for a SN visit frequency of three times a week for eight weeks, then once every week for one week. Documentation showed during the week 10/22/23 to 10/28/23 no SN visit was conducted (one visit ordered, one visit missed [electronic documentation system message showed not started]). Documentation showed no patient/caregiver refusal of the SN visits, no physician notifications and no change in orders. On 10/31/23 at 12:58 p.m., Staff B stated the SN should have conducted and documented the SN visits as ordered in the POC. Patient #8 A review of a POC dated 08/31/23 to 10/29/23 showed orders for an OT to evaluate. Documentation showed no OT evaluation visit was conducted (one visit ordered, one visit missed). Documentation showed no patient/caregiver refusal of the OT evaluation visit, no physician notifications and no change in orders. On 10/31/23 at 1:04 p.m., Staff B stated the OT should have conducted an evaluation visit as ordered in the POC. Patient #12 A review of the POC dated 09/27/23 to 10/23/23 showed orders for SN to conduct care of an intravenous access device (PICC) line every visit. Documentation showed no intravenous access device (PICC) line care was conducted during SN visits on 10/23/23. Documentation showed no patient/caregiver refusal of intravenous access device (PICC) line care and assessment, no physician notification and no change in orders. On 10/31/23 at 1:07 p.m., Staff B stated the SN should have conducted a PPICC line dressing change during the SN visit as ordered in the POC. Patient #14 A review of the POC dated 06/19/23 to 07/26/23 showed orders for SN to assess, monitor and instruct the patient’s weight every visit. Documentation showed no assessment or monitoring of the patient’s weight was conducted during SN visits on 06/21/23, 06/28/23, 07/13/23, 07/19/23 and on 07/26/23. Documentation showed no patient/caregiver refusal of assessment or monitoring of weight, no physician notifications and no change in orders. On 10/31/23 at 1:15 p.m., Staff B stated the SN should have conducted assessment and monitoring of the patient’s weight during the SN visits as ordered in the POC.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure SN visit notes were started, completed and authenticated for six (Patients #2, 4, 5, 7, 11 and 13) of 20 patients. Findings: Patient #2 A plan of care dated 09/13/23 to 11/11/23 documented a principal diagnosis of stage 2 pressure ulcer. Documentation showed a SN visit frequency of two times a week for one week, three times a week for one week, two times a week for one, then one time a week for six weeks. Documentation showed SN visits notes on 10/20/23, 10/24/23 and on 10/27/23 were not started (blank), completed and authenticated by the SN. Patient #4 A plan of care dated 10/04/23 to 12/12/23 documented a principal diagnosis of congestive heart failure. Documentation showed a SN visit frequency of one times a week for nine weeks. Documentation showed SN visits notes on 10/19/23 and on 10/27/23 were not started (blank), completed and authenticated by the SN. Patient #5 A plan of care dated 10/19/23 to 12/17/23 documented a principal diagnosis of subdural hematoma. Documentation showed a SN visit frequency of one times a week for eight weeks. Documentation showed SN visits notes on 10/25/23 was not started (blank), completed and authenticated by the SN. Patient #7 A plan of care dated 09/09/23 to 11/07/23 documented a principal diagnosis of stage 2 pressure ulcer of the sacrum. Documentation showed a SN visit frequency of three times a week for eight weeks, then one time a week for one week. Documentation showed SN visits notes on 10/16/23 was not started (blank), completed and authenticated by the SN. Patient #11 A plan of care dated 09/06/23 to 11/04/23 documented a principal diagnosis of hypertension. Documentation showed a SN visit frequency of one times a week for nine weeks. Documentation showed SN visits notes on 10/24/23 was not started (blank), completed and authenticated by the SN. Patient #13 A plan of care dated 09/29/23 to 11/27/23 documented a principal diagnosis of coronary artery disease. Documentation showed a SN visit frequency of one times a week for nine weeks. Documentation showed SN visits notes on 10/20/23 and on 10/27/23 were not started (blank), completed and authenticated by the SN. On 10/31/23 at 12:47 p.m. to 1:10 p.m., Staff B stated visit notes are to be accepted by the staff at the start of the visit and completed and signed by staff within 24 hour of the visit for patients #2, 4, 5, 7, 11 and 13.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a completed discharge summary was provided for five (Patients #14, 15, 16, 18 and #19) of 20 patients. Findings: Patient #14 A review of the clinical record documented discharge from the agency on 07/26/23 to hospice service provider. Documentation showed no discharge summary was provided to the hospice service provider. Patient #15 A review of the clinical record documented discharge from the agency on 09/29/23. Documentation showed no discharge summary was provided to the physician service provider. Patient #16 A review of the clinical record documented discharge from the agency on 10/12/23 to inpatient hospital service provider. Documentation showed no discharge summary was provided to an inpatient hospital service provider. Patient #18 A review of the clinical record documented discharge from the agency on 09/16/23. Documentation showed no discharge summary was provided to the physician service provider. Patient #19 A review of the clinical record documented discharge from the agency on 08/26/23. Documentation showed no discharge summary was provided to the physician service provider. On 10/31/23 at 1:15 p.m. to 1:30 p.m., Staff B stated documentation showed no discharge/transfer summary was provided to the physician of record and the receiving service providers for patients #14, 15, 16, 18 and #19 at the time of discharge from agency services.